neonatal infant spine and hips

US has equaled MRI in quality for detecting certain ______ anomalies.

Spine

Which imaging modality was used for this scan?

MRI

Which imaging modality was used for this scan?

US

The neural tube and spinal cord arise from __________ cells.

Ectodermal

Defects in the spine will typically occur in the first __ weeks of life.

8 ½

What are the 3 fetal spine separations?

• Incomplete

• Premature

• Failure

The incomplete separation of the (1)_________ occurs from the (2)________.

1. Neural tube

2. Ectoderm

The incomplete separation of the neural tube could result in what 3 pathologies?

• Cord tethering

• Dermal sinus

• Other spinal defects

The premature separation of the (1)________ from the (2)__________.

1. Ectoderm

2. Neural tube

Premature separation of the ectoderm can result in abnormal (1)________ elements, such as (2)_______ forming between the (3)_________ and the (4)_____.

1. Mesenchymal

2. Lipomas

3. Neural tube

4. Skin

If the neural tube fails to (1)____ and (2)____ in the midline, defects such as (3)___________ occur.

1. Fold

2. Fuse

3. Myelomeningocele

What are the 3 indications for a neonatal spinal US?

• Congenital anomalies

• Suspicious sacral dimple

• Soft tissue mass suspected of being spina bifida occulta

A defect on the lower midline back will be suspected for what pathology?

Sacral dimple

A sacral dimple will lie above the…

Gluteal crease

A sacral dimple has a possibility of being…

Drained

A sacral dimple can go through skin changes, which includes having a (1)___________ or (2)___________.

1. Hairy patch

2. Skin tag

Tethered cords have an association with neonates with…

Imperforate anus

What is the pathology seen here?

Sacral dimple

What are some additional indications that are not as common for a neonatal spine US?

• Lipomas

• Hydromyelia

• Myelomeningocele

• Myeloschisis

Lipomas are (1)______ tumors composed of (2)____ cells.

1. Benign

2. Fat

Hydromyelia is the (1)_______ of the central canal of the…(2)

1. Dilation

2. Spinal cord

Myelomeningocele is seen in patients with (1)___________ with a portion of the (2)__________ and (3)__________ protruding through the defect.

1. Spina bifida

2. Spinal cord

3. Membranes

Myeloschisis is a (1)______ spinal cord resulting from failure of the (2)____________ to close.

1. Cleft

2. Neural tube

The vertebral column extends from the (1)_____________ to the (2)____________.

1. Base of the skull

2. Tip of the coccyx

The vertebral column extends along the ________ surface of the body.

Posterior

Within the vertebral cavity, there are what 3 things?

• Spinal cord

• Roots of spinal nerve

• Covering meninges

The vertebral column consists of __ vertebrae.

33

The vertebral column consists of…

1. __ cervical

2. __ thoracic

3. __ lumbar

4. __ sacral

5. __ coccygeal

1. 7

2. 12

3. 5

4. 5

5. 4

The sacral vertebrae fuses to form the…

Sacrum

The coccygeal vertebrae fuses to form the…

Coccyx

In neonates, problems typically occur in the lower back of the (1)_____________ and (2)______.

1. Lumbar vertebrae

2. Sacrum

Label the sections of the vertebral column.

1. Cervical

2. Thoracic

3. Lumbar

4. Sacral

5. Coccyx

Each vertebrae consists of a (1)____________ anteriorly and a vertebral (2)_______ posteriorly.

1. Rounded body

2. Arch

The vertebrae encloses a space called the…

Vertebral foramen

The vertebral foramen protects the (1)___________ and its (2)___________.

1. Spinal cord

2. Coverings

‘L5’ is the only vertebrae labeled on this image. Label the empty numbered space vertebrae.

1. T12

2. L1

3. L2

4. L3

5. L4

6. S1

7. S2

8. S3

9. S4

10. S5

To know all the bones consisted in the sacrum on an US scan, you would count backwards from…

S5

On a neonatal spine US, why is the vertebrae labeled?

For the doctor

All sacral vertebrae are…

Curved

The coccyx will be mostly or completely (1)_________ and (2)________.

1. Unossified

2. Hypoechoic

On a neonatal spine US, the coccyx is typically…

Not seen

Label the vertebrae if ‘S5’ is the only one still labeled here.

1. L5

2. S1

3. S2

4. S3

5. S4

What structure is pointed at by this blue arrow?

Coccyx

The size and shape of the spinal cord varies along its…

Length

The spinal cord is narrowest in what region?

Midthoracic

The filum terminale is a ____, ________ connective tissue.

Thin, echogenic

The filum terminale extends inferiorly from the (1)______________ to the (2)_______.

1. Conus medullaris

2. Sacrum

The filum terminale should measure less than…

2 mm

Inferiorly, the spinal cord tapers off into the…

Conus medullaris

What fluid surrounds the spinal cord?

Cerebrospinal fluid

Describe how the spinal cord appears sonographically.

• Hypoechoic

• Echogenic borders

• Echogenic line extends longitudinally along midline

Label the parts of this scan that are crossed out.

1. Conus medullaris

2. Filum terminale

1. What structure is seen at the red arrow?

2. Yellow arrow?

1. Spinal cord

2. Filum terminale

The echogenic border of the spinal cord is referred to as the…

Thecal sac

The thecal sac is the (1)______________ that covers the (2)__________.

1. Protective membrane

2. Spinal cord

The central echogenic complex in the spinal cord represents what?

Cord’s central canal

Looking at this image of the filum terminale, would this be normal or abnormal?

Normal, based on sonographic appearance and measurement

Looking at this image of the filum terminale, would this be normal or abnormal?

Abnormal, filum terminale looks thick and spinal cord appears tethered

The ventriculus terminalis is a slight (1)__________ or (2)__________ of the central canal at the (3)______ end of the cord.

1. Prominence

2. Widening

3. Caudal

The ventriculus terminalis is a ________ finding in neonates.

Common

The ventriculus terminalis is a _________ variant.

Anatomical

What are some other terms for ventriculus terminalis?

• Terminal ventricle

• 5th ventricle

Since ventriculus terminalis is a normal variant, when can it typically disappear?

Within the first few months of life

Ventriculus terminalis is typically positioned at the transition of the tip of the (1)______________ to the origin of the (2)________________.

1. Conus medullaris

2. Filum terminale

Label the image seen here.

1. Conus medullaris

2. Ventriculus terminalis

3. Filum terminale

The tip of the arrow points to a normal variant. What can be assumed here?

Ventriculus terminalis

The tip of the arrow points to a normal variant. What can be assumed here?

Ventriculus terminalis

What is another term for transient dilation of the central canal?

Syrinx

Transient dilation of the central canal is a slight ________ in newborns.

Enlargement

Transient dilation of the central canal usually disappears when?

Within the first few weeks of life

What are the differences and similarities between ventriculus terminalis and transient dilation of the central canal?

Differences: Transient dilation of the central canal will have a slightly larger dilation than ventriculus terminalis

Similarities: Both resolve on their own

The pathology seen here was found on a recently birthed newborn. What can be assumed here?

Transient dilation of the central canal

A filar cyst is a _______ variant.

Normal

A filar cyst is a (1)_________ cyst like-structure that is usually an (2)________ finding.

1. Elongated

2. Incidental

Filar cysts tend to be located in the…

Filum terminalis

Between the ventriculus terminalis, transient dilation of the central canal, and filar cysts; which is the most common?

Filar cyst

This cyst like structure was found in the filum terminale. What can be assumed here?

Filar cyst

The lower nerve roots together are called…

Cauda equina

The spinal nerve roots unite to form a…

Spinal nerve

__ pairs of spinal nerves are attached along the length of the spinal cord.

31

The cauda equina descends from the (1)___________, below the (2)_____________.

1. Spinal cord

2. Conus medullaris

1. What plane was this image taken in?

2. What are the arrows pointing to?

3. Why does it appear this way?

1. Transverse

2. Clumping of nerve roots on the left

3. LLD

1. What plane was this image taken in?

2. What are the arrows pointing to?

1. Longitudinal

2. Mass-like appearance of nerve roots

The spinal cord should lay (1)___ to (2)___ towards the (3)_________ vertebrae in the spinal cord.

1. 1/3

2. Half way

3. Anterior (ventral)

The spinal cord position allows it to be (1)_________________ and (2)______________.

1. Gravity dependent

2. Free floating

The spinal cord position will have a _________ pulsatile movement.

Normal

To prove the pulsatile movements of the spinal cord, what can be done?

• Use M-Mode

• Cine loops

Is this transverse image normal or abnormal?

Normal

Why are spine USs performable on infants but not adults?

Due to the incomplete ossification of the spine

1. What plane was this image taken in?

2. The arrow points to the end of the conus medullaris, is this a normal location for it to end?

1. Longitudinal

2. Yes, ends between L1 and L2

What plane were these images taken in?

Transverse

1. What exam is being performed here?

2. How is the fetus positioned for this exam?

1. Neonatal spine

2. Prone or LLD

How is the fetus positioned for a neonatal spine US?

• Prone

• LLD

The transducer is placed from a __________ viewpoint.

Posterior

The prone position for a neonatal spine US will have the spine (1)________ to separate the (2)________ spinal elements. The slight (3)___________ to the upper body to distend the (4)_________ aspect of the spine.

1. Flexed

2. Posterior

3. Elevation

4. Caudal

What kind of transducer should be used for a neonatal spine US?

• Highest frequency linear transducer

  • Smaller neonates will require higher frequencies (15 MHz)

  • Larger neonates will require lower frequencies (8-12 MHz)

Neonatal spinal US are performed at (1)__________ for sagittal images and in (2)______ planes for transverse.

1. Midline

2. Axial

What is one of the most common reasons for an ordered neonatal spine US?

To view the level of the tip of the tapered conus medullaris

The conus medullaris will most commonly terminate at…

L1 and L2

The lumbar vertebral may be determined on an US in several different ways. List two ways.

• Counting back from S5

• Seeing where the vertebrae starts to curve (indicates S1)